Provider Demographics
NPI:1558617399
Name:GLORY CENTER, P.A.
Entity Type:Organization
Organization Name:GLORY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:O
Authorized Official - Last Name:IKUDAYISI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-495-2234
Mailing Address - Street 1:6641 MADISON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-1966
Mailing Address - Country:US
Mailing Address - Phone:727-232-0826
Mailing Address - Fax:727-597-8487
Practice Address - Street 1:6641 MADISON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-1966
Practice Address - Country:US
Practice Address - Phone:727-232-0826
Practice Address - Fax:727-597-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGJ105AMedicare PIN